Sleepwalking Clinical Presentation

Updated: Mar 11, 2019
  • Author: Syed M S Ahmed, MD; Chief Editor: Selim R Benbadis, MD  more...
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Presentation

History and Physical Examination

The most common pediatric parasomnia disorders of arousal include sleepwalking, confusional arousals, and sleep terrors. [19] Parasomnia events have a predilection for occurring during deep sleep (stages III and IV, or slow-wave sleep [SWS]), are known to occur during all stages of non−rapid eye movement (NREM) sleep, and are possible at any time during the night. Because most SWS is achieved in the earlier segments of the sleep period, these phenomena are usually seen in the first one third of the sleep cycle and are rarely seen during naps.

A general medical history and sleep-related medical history are usually sufficient to permit differentiation of parasomnias from other disorders. Pertinent issues include the following:

  • Detailed description of the event

  • level of consciousness before, during, and after the event

  • Time of night and sleep cycle when the events occur

  • Daytime sleepiness

  • Associated injury

  • Memory of the event

  • Family history

  • Any precipitating factors

Nocturnal frontal-lobe seizures and some psychiatric conditions present the most difficult diagnostic dilemmas. A history of stereotypical short attacks that repeat during the night, most frequently during stage II sleep, suggests seizures rather than a parasomnia. Onset in later childhood or adolescence, persistence into adulthood, recurring nocturnal agitation, and daytime complaints such as fatigue or sleepiness are also suggestive of a seizure disorder.

Sleepwalking episodes may range from quiet walking about the room to agitated running or attempts to “escape.” Subjects may later report attempting to escape dangerous situations or terrifying threats. Typically, the eyes are open and have a glassy, staring appearance as the child quietly roams the house.

On questioning, the child’s responses are slow or absent. If returned to bed without awakening, the child usually does not remember the event. Older children, who may awaken more easily at the end of an episode, often are embarrassed by the behavior (especially if it was inappropriate).

Sleepwalking has no association with previous sleep problems, sleeping alone in a room or with others, achluophobia (fear of the dark; also referred to as nyctophobia, scotophobia, or lygophobia), or anger outbursts. Some studies suggest that children who sleepwalk may have been more restless sleepers when aged 4-5 years and may have been more restless with more frequent awakenings during the first year of life.

Differentiation from confusional arousals and sleep terrors

Episodes of confusional arousal consist of disorientation, memory impairment, and slow mentation and often are accompanied by inconsolable crying and thrashing movements in bed. This disorder is common in younger children but decreases in frequency with age. In infants, episodes manifest by crying and moving about in bed. The eyes may be closed or opened, as in sleep terrors, but the child does not appear to feel panic.

Events typically last from 3-13 minutes and range in frequency from 2 times per night to 2 times per year. Attempting to awaken the child often prolongs the course, and successful wakening by parents typically brings about an end to the episode.

Sleep terrors are the most anxiety-provoking parasomnias for parents. Episodes frequently begin with a “blood-curdling” scream, which is accompanied by the appearance of panic with wide-open eyes, tachycardia, tachypnea, dilated pupils, diaphoresis, and flushing. This may be followed by panic-driven motor activity, such as hitting the wall or running around the room. Although the behavior typically is not dangerous, it is sometimes violent enough to result in injury to the patient or others; property damage also may result.

The inability of the parent to console the child is a hallmark of the episode (which is typically shorter than confusional arousals), and amnesia for the event is usually complete. Sleep terrors usually resolve by adolescence, though the disorder occasionally persists into adulthood.

Physical and neurologic examinations are typically normal in these children.